Moving Through Hospitals: Designing Handwashing

In October, 2008, Medicare—the United States' government program that pays 40% of the nation's hospital bills—decided to stop covering hospital failures. This meant that a litany of preventable mistakes, including treatments resulting from surgical errors, patient accidents and infections, were now the financial responsibility of the hospital. As a result, medical accidents went from being a source of hospital revenue to a massive financial drain. The good news is that medical institutions were finally forced into the business of disease prevention, at least once people were in their care.

What can be done to prevent costly medical mistakes? The hospital reform with the greatest potential is also the easiest to implement, at least in theory. According to the Committee to Reduce Infection Deaths statistics, hospital acquired infections kill more people in America than AIDS, breast cancer and auto accidents combined. Furthermore, the vast majority of the patients that acquire such infections in hospitals—and more than 5 percent of patients do—get them from the hands of health care providers. Thankfully, hospitals have become increasingly concerned with hand hygiene. The dirty hands of doctors and nurses aren't just gross—they are an extremely expensive and potentially fatal act of carelessness. Hospital staffers, in order to follow protocol, need to wash their hands hundreds of times a day. Their failure to follow protocol perfectly is their personal responsibility but non-compliance on such a broad scale is also a failure of the medical system that creates the rules and environment that lead non-compliance.

The medical industry's acknowledgment of hand hygiene as a systemic problem has led to the establishment and growing influence of Infection Control and Prevention Units. For Infection Control and Prevention, solving handwashing takes the form of cheeky posters of doctors reminding everyone to wash their hands, developing inane training videos demonstrating how to properly wash your hands and implementing incentive programs where health care workers reward each other with certificates when they observe a co-workers consistent compliance. In the hospital where I have focused my research, these certificates were returned unused.

One increasingly popular but misguided program has to been to implement paternalistic monitoring of nurses and other providers, who are forced to undergo increasing levels of surveillance. Whether it is video monitoring systems borrowed from meat manufacturing plants or sensor systems that read the alcohol content on hands, staff are cajoled into changing their behavior by receiving real time feedback combined with their fear that their personal compliance level is now public knowledge. There is no carrot—there is only a stick.

Despite growing desperation, few designers have bothered to do much of anything that might make washing or sanitizing hands more appealing. A recent scientific study pointed to "perceived busyness" as one of the primary deterrents to compliance. But this only demonstrates the silliness of current reforms. After all, if followed literally, the prescribed protocol for hand cleaning would require so much of the health care workers time that they wouldn't actually be able to perform the rest of their job. During a recent observation, nurses were consistently walking from supply closets to narcotic storage bins to patients rooms with their hands full. How, then, can they follow protocol and wash their hands correctly when they enter the room? Are monitoring systems supposed to solve these problems? Or are we merely putting increased strain on an already stressed population without offering any design solutions?The problem is twofold. Behavior change is being required in a highly prescribed environment, where seemingly simple solutions like having more hand sanitizer placed around the hospital conflicts with fire code regulations, as sanitizer is alcohol-based. On top of these environmental restrictions, the actual job of health care workers is so incredibly taxing that there is no time or energy for additional tasks. Such constraints make clear that we need better design, and simply throwing more technology or thoughtless regulations into the mix doesn't actually seem to address the problem. But what kind of design problem is this?

Movement Design
I've spent a large part of the past quarter century concerned with the subtleties of my own physical performance. I am a professional modern dancer and designer. To talk about dance and design broadly is easy. One can mention moving through space, gestural systems and human factors. Referring to the "choreography" of design is becoming more common. As a graduate student in the Transdisciplinary Design program at Parsons, my work in the classroom, on stage and in the hospital has been to understand how my movement thinking in dance can be transposed to effect problems that have movement design at their core.

Working in partnership with an Infection Control and Prevention team and a health care designer, I have been addressing the feel and subjectivity of the kinetic experience of handwashing. To a certain extent I am practicing a very literal form of problem-solving, attempting to solve handwashing by actually watching how people wash their hands. But this turns out to be a surprisingly fruitful perspective. By looking at the medical problem from the perspective of movement, it immediately becomes clear that there are three primary principles worth exploring.

Muscle Memory

Our bodies know a lot. Consider the Iowa Gambling Task, a famous scientific experiment where the sweat on a participants palms when hovering over a losing deck suggested that the players body knew they were picking from a bad deck long before the players consciously did. Many of our daily interactions rely on our bodies ability to evaluate situations and make decisions moments before we consciously consider anything. This is in part because of muscle memory—learned movement patterns embedded in our bodies. Standardized spaces, movements and interactions consistently draw on our muscle memory. Ideally, all hand sanitizing dispensers would be in the exact same relationship to a door knob or bed frame but a lack of coordination between those who layout a fire sprinkler system, patient rooms and hand sanitizers (which are flammable) inhibits the spatial and movement standardization of hand sanitizing. In most hospitals, because of their random placement, every dispenser and room requires a different physical coordination for compliance, never creating consistent muscle memory. If movement isn't included in the design and structure of spaces from the beginning, our body's innate abilities will be underutilized and behavior steering will come at a much higher cost.

Movement Scripts
Design, especially interior architecture and industrial design, scripts our movement. Sadly, much of this impact is unintentional. In dance and improvising there is a fair amount of wiggling around and doing what feels good and easy but there is also an amazing potential for developing a type of movement logic. Call it structured improvisation or call it decision architecture but giving movement a framework to exist within is when innovation happens. It's when idiosyncrasies arise and turn into polyrhythmic phrases; it's when the accidental juxtapositions are exposed and result in new sensations; it's when new techniques emerge and evolve. Exploring and moving differently requires well situated and behaviorally appealing prompts and structure. Looking at physically embedded movement sequences (i.e. handwashing in places like bathrooms, whether at home, work or restaurants is usually accompanied by looking in the mirror) can give us insight into scripts that resonate and create best practices.
Freedom and Fluidity
What allows nurses to be compliant despite the awkward placement of a hand sanitizing dispenser? Some nurses develop movement transitions and subtle body negotiations that result in seamless interactions between them and the sanitizing equipment. In a series of fluid movements, they typically pin their papers between their bicep and rib cage, release one arm to swing between the dispenser and its plastic lip and then rub their hands together in a complicated and vigorous duet of fingers. While this is happening, they are also greeting their patients. Like an Olympic hurdler, the movements are all seamlessly calibrated; the professionals compensate for the failed ergonomics of their environment.

These three areas of interest are my physical lenses for re-designing handwashing. Dr. Jay Parkinson, founder of Future Well, calls the medical field, not just uncreative but anti-creative. The hierarchies, regulations and intricately fused systems in hospitals keep experimentation at bay, which makes the observation, acknowledgment and promotion of experimentation by those within the hospital essential. In focusing on the movement of individuals, I strap myself clearly to the optimistic side of the problem. I need the commitment of already dedicated individuals rather than institutional adoption. Hospital staff, with all of their limitations, are drawn to creative solutions. Their need to satisfy patients, superiors and protocols for 12 hour shifts require regular feats of physical gymnastics. Not only are these feats going unacknowledged but they are also going unstudied. In a society driven by sight, our own physical behaviors are under examined and under designed. For me, physical behaviors frame the problem, research and solution. Rather than creating systems to observe or remind people to strive for nearly impossible goals in a poorly designed environment, designers need to grapple with all the good reasons why health care workers aren't sanitizing their hands and look to the staff for solutions. Patients and health care workers deserve more from design.

Of course, unique perspectives are not solutions and hospitals are filled with "human-centered" practitioners. Together with them, my approach and designs are becoming real and felt in the hospital and infection control departments. Shifting perspectives and shifting bodies are colliding. I've written my diagnosis, now come back for part 2 in April to see what kind of doctor I really am.

About Rachel LehrerRachel Lehrer is designer, dancer and soon-to-be graduate of the MFA Transdisciplinary Design program at Parsons. Her work centers around the question: how can we optimize our body's intelligence to improve performance? Through years of movement, choreographic and improvisational practice she's gained expertise in physical learning, tacit knowledge, movement analysis, movement scripting and conducting deeply felt research that vacillates between being highly structured and improvisatory. Rachel also likes writing, rehearsing and making videos about people, ideas and designs that matter to her.

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Great article. I recently worked on a research proejct 'Designing Out Medical Error' which you may find interesting. We look at both infection control and hand hygiene in the hospital. One of our design outcomes 'The CareCentre' aims to place the hand gel at the end of every bed, so it is always consistent, it is also next to a flat surface so staff can put down their notes before using the gel (we also observed this was a big issue - people not being able to clean their hands as they were carrying things).
The hand hygiene outcome was more of a campaign approach, but again introducing consistency, developing a universally recongnisable symbol for hand hygiene, and also coming up with fun ways to raise awareness and reward staff.
Hope you find it interesting, we certainly found the project very challenging but rewarding.

Great article- indeed such a highly relevant and important topic. You've got to get in touch with these guys from SwipeSense. http://swipesense.com/ They are starting a company around this very specific issue! Currently in the Healthbox incubator, this team aims to build on the intuitive hand hygiene movements to make sanitation compliance easier. I'll forward them this article too!

This is a great challenge. I am excited to hear about some of the design research going into it. It seems that the problem statement shouldn't be "how to get workers to wash their hands?". Shouldn't it be "how to prevent germ transmission?". Because of course how much hand washing can/should a person do? Observing my wife's years in medicine I have seen her hands become red, painful, chapped, cracked appendages due to constant hand washing. When the procedure calls for hand washing a hundred times a day, 5 or 6 days a week for years on end that highlights a flaw in the system. Good luck with your research. It is a very worthwhile endeavor.

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